No 13/14 - 2018

Free measles vaccination for non-immune adults

On 1 April 2018, an offer was introduced of free measles vaccination for adults. The offer covers people who have not already received measles vaccination or had measles. You can be vaccinated free of charge at your GP or at a private vaccination clinic. Read more in the relevant executive order and guideline (both in Danish).

The offer includes one MMR vaccine, which protects against measles as well as mumps and rubella. Practically all persons born before 1974 have had measles and are therefore immune. Testing to determine the immune status is not offered before vaccination.

Even though Denmark has used a two-dose MMR vaccination programme for more than 30 years and has now eliminated measles, EPI-NEWS 37/17, a group of people, particularly among younger adults up to around 45 years of age, have not been vaccinated in childhood and have not had the condition as it has been rare during most of their life span. When Danes travel to countries where measles virus is still in circulation, they are at risk of being exposed and falling ill if they have not received vaccination or previously had measles. This also applies when travelling to other countries within Europe. Returning travellers with measles may therefore infect non-immune people in Denmark. Therefore, the health authorities recommend being vaccinated when staying in Denmark and before any foreign travel.

Background

MMR vaccination was introduced into the Danish childhood vaccination programme on 1 January 1987, EPI-NEWS 9/86 and 46/86. When the programme was initiated, persons under 13 years of age born in 1974-1986 were offered a single dose of MMR vaccine. Practically all persons born before 1974 have had measles and are therefore naturally immune. The coverage of the catch-up programme varied and depended on the child’s age; for children born in 1976, the coverage was 31%, EPI-NEWS 35/89, whereas it was 84% for children born in 1986, EPI-NEWS 6/07.

In the period before 1987, all three diseases were very common, e.g. measles epidemics occurred every 2-3 years and Denmark typically saw a total of 20-60,000 annual cases. After the introduction of the MMR vaccination, the number of cases rapidly dropped to approx. 500 annual cases. Concurrently, the frequency of measles complications such as measles pneumonia, bacterial super infections (e.g., pneumonia and otitis media) measles encephalitis and death also decreased.

In the following years, the number of cases decreased even more, and in 1997 a total of 61 cases were recorded. During a 31-month honeymoon period in 2002-2005, no cases were notified, after which measles cases started being seen in Denmark again, but to a limited extent and usually in connection with introduction of virus into Denmark following foreign travel to known endemic areas.

In 2011, a major measles epidemic occurred counting 84 cases of whom 1/3 were younger adults. Among these, approx. 70% were admitted to hospital, EPI-NEWS 24/11. This outbreak was the reason why MMR vaccination was offered during a limited period in 2012 to all adults born in or after 1974, EPI-NEWS 12/12. This temporary programme had a low coverage, as only approx. 2,000 persons from a target group of 70,000-100,000 non-immune younger adults were vaccinated, EPI-NEWS 16/13.

Suboptimal but increasing vaccination coverage

Measles virus is one of the most infectious viruses we know of. Therefore, at least 95% of all children must have received two MMR vaccinations to ensure that the virus will not continue to circulate in the population. Despite the fact that the vaccination coverage of both MMR vaccines has been increasing over the past 5-6 years, the required coverage has not been reached for any birth year since the introduction of the vaccine. This means that the number of non-immune adults has been accumulating in the course of the years.

When measles virus is imported to Denmark following travels to an area where it is in circulation, limited further transmission may occur in Denmark. In this context, non-immune young adults and unvaccinated children (normally below 15 months of age) in particular will be at increased risk of infection. This is why MMR vaccination is now offered to all non-immune adults. Along with continued enhanced vaccination measures among children, the vaccination offer to adults may contribute to maintaining Denmark’s status as a country that has eliminated measles.

Measles is still widespread in Europe

Measles is still common in Europe; according to the WHO, the number of recorded cases in 2017 quadrupled compared with 2016. In 2017, a total of 21,315 cases were recorded along with 35 deaths among the European WHO region’s 53 member countries. Major outbreaks were recorded in the Ukraine, Romania and Italy; and among the EU’s 28 member countries, measles remains endemic in Belgium, France, Italy and Romania. The ECDC’s website continuously updates the number of reported measles cases per month in the EU/EAA countries.

Vaccination programme

The currently used MMR vaccine (M-M-R VaxPro^®) provides protection against measles in 95% of vacinees after a single dose. As individual protection is thus very high, it is considered sufficient to offer adults a single dose of MMR vaccine in the catch-up programme.

No risk is associated with vaccinating a person who has already achieved measles immunity, and it is therefore not recommended that measles antibodies are measured prior to measles vaccination.

Furthermore, MMR vaccination carries no risk for people who have had mumps and/or rubella. If you are already immune to one or both conditions, the circulating antibodies will simply neutralise the corresponding part of the vaccine.

Rubella

Rubella infection is not a serious disease in children, but may have serious sequelae for the foetus if a pregnant woman is infected in her first trimester. For many years, unvaccinated women above 18 years have therefore received rubella vaccination free of charge, given as the MMR vaccine. Rubella infection in pregnant women and congenital rubella syndrome have been individually notifiable since 1994; and a total of 19 cases of rubella infection in pregnant women have been recorded since then (most recently in 2008), while no cases of congenital rubella have been recorded.

Adult women, whose immunity status is unknown, receive rubella vaccination without previously establishing their immunity status. MMR vaccine must be given at least one month before pregnancy.

Side effects

Like any other pharmaceutical, the MMR vaccination can cause side effects. The most common side effects reported with the use of M-M-R VaxPro^® are: fever > 38.5°C, local vaccination site reactions including pain, swelling and erythema. In adult women, incidence rates for arthritis and joint pain are generally higher than those seen in children (12-20%), and the reactions tend to be more marked and of longer duration. Significant immunodeficiency and pregnancy are contraindications. For information about non-common and rare side effects and other contraindications, please see the Summary of Product Characteristics of the MMR vaccine (M-M-R VaxPro^®), which is available at SSI’s website (in Danish).

How to order

As always, MMR vaccines are ordered via the SSI Order Office, and supplied in 10-dose packages.

Settlement with the national health service and registration in the DVR

When giving MMR vaccination in conjunction with another consultation, code 8802 is used. When giving MMR vaccination independently, code 8802 is used along with code 8901 (“injection fee”). As foreign travel may be associated with a measles risk, vaccination clinics may also offer free MMR vaccination of adults who will be going abroad. Settlement with the regions must be done electronically using the settlement systems recommended by the regions.

Furthermore, since November 2015, it has been a legal requirement to record all given vaccines in The Danish Vaccination Register (DVR).

(P. H. Andersen, L.K. Knudsen, P. Valentiner-Branth, Department of Infectious Disease Epidemiology and Prevention, B. Søborg, S. Ulendorf Jacobsen, Danish Health Authority)

Link to previous issues of EPI-NEWS

4 April 2018